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CLINICAL NUTRITION: Clinical Nutrition in Surgery - Coggle Diagram
CLINICAL NUTRITION: Clinical Nutrition in Surgery
Surgery
Types of surgery
Planned- nutrition important for prep
Emergency- cannot prepare patient nutritionally for surgery but can post surgery (ERAS)
Surgery is a type of trauma (physical)
Direct injury: occurs through surgical access, organ mobilisation, excision and dissection
cytokine and inflammatory mediator release, which drive immunologic, metabolic and hormonal processes in the body known as the surgical stress response
Indirect injury: occurs through a number of methods including blood loss, alterations in perfusion, microvascular changes and from anaesthetic techniques
The surgical stress response (see slides 8/21 on surrey learn for diagram)
neuroendocrine-metabolic response AND inflammatory-immune response
Inflammatory response: cytokines and acute phase reactants made (liver produces CRP in inflammatory response)
Principles of metabolic and nutritional care for patients undergoing surgery
Need to avoid long periods of preoperative fasting / poor preoperative nutritional status as afterwards more difficult to recover (will have less storage ) - fasting can make patients more stressed, inducing further stress response
Re-establish feeding orally ASAP afterwards to recover further
Nutritional screening prior to surgery
Malnutrition screening: MUST score (BMI and percentage of weight loss , Albumin levels <30g/l with no evidence of hepatic or renal dysfunction before operations (if too low, CRP may be high then likely unwell) . Preoperative serum albumin prognostic factor for complications after surgery
initiate nutritional therapy if patients are expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than 7 days
patients with severe nutritional risk shall receive nutritional therapy prior to major surgery
Pre-operative fasting
used to prevent pulmonary aspiration during surgery but this is not evidence based= unnecessary in most patients (can drink clear fluids until 2 hours before anaesthesia and solids 6 hours before
Avoidance of fasting is a key component of enhanced recovery after surgery (ERAS) = aim to minimise nutritional depletion peri-operatively
Exceptions are those with emergency surgery or GORD/ delayed gastric emptying
Preoperative CHO treatment
drinking CHO can improve insulin resistance after surgery
400mls - 800 mls (around 50g -100g CHO) night before and 400mls (around 50g carbs) 2 hours before surgery
not for patient with diabetes , especially anticipated gastroparesis
Attenuate postoperative insulin resistance, reduces nitrogen and protein losses, preserves skeletal muscle mass and reduces preoperative thirst, hunger and anxiety
Oral nutirtional intake after surgery
continue after surgery without interruption, within hours in most patients
amount should be individualised
good evidence only available for patients undergoing colorectal surgery
Combined Parental nutrition support
if intake <50% requirements for more than 7 days, combo of enteral and parental nutrition recommended
combined nutrition not needed if expected time period of PN is <4 days
if expected PN period is expected to last between 4 and 7 days, may consider peripheral PN but note many hospitals do not allow peripheral PN
Tube feeding
Glutamine (most abundant and versatile AA in body)
theory- to supplement to boost levels as needed for metabolism, nutrgoen exchnage via ammonia transport between tissues and pH homeostasis
ESPEN (2021)- consider parenteral in those who cannot be fed adequately enterally but no strong evidence - no strong evidence for oral glutamine
Nutritional Requirements
ESPEN surgery guidelines- ideal body weight (25-30kcals/kg for energy and 1.5g/kg for protein)
PENG 2019- based on clinical conditions however limited evidence and not available for all conditions
for critically ill patients, a few equations available